Click here Today we covered some key areas in surgery for the acem exam.
The 4 key patterns of presentation include
embolic - AF or ventricular aneurysm related - 50% of all MI
low flow states
each of these have a specific risk factor profile which are distinct
recognising aetiology, sensitive or specific findings on clinical assessment, and diagnosis on CTA is important, as well as severity grading or assessment of complications such as infarction and organ failure is key.
Management options of
laparotomy for bowel resection or
vs angiography for clot retrieval or local papaverine is considered
diagnostic criteria - 2 of 3 - lipase Elevation, clinical features, imaging findings
classification -oedematous vs necrotic
severity assessment - based on organ failure
prognostic scores : be ale to compare and contrast
- BISAP - renal function, effusion, gcs, sirs, 60 yo
ransons, apache, sirs,
have some knowledge of imaging of the pancreas
Toxic megacolon was covered in detail, reviewing the 2 common presentations from IBD or clostridium difficile. Imaging diagnosis of tvs colon > 6 cm and
diagnostic criteria including systemic illness and anaemia, wcc elevation, sirs
the treatment options varied with underlying cause
associations of metabolic alkalosis, hypokalaemia, dysmotility agents
Clostridial infecting and predictors or risk factors for clostridial such as antibiotic use, COPD, hospital admission were discussed in detail.
Lastly we covered MCQ golden rules:
read the question
assess if you have the knowledge in an area, or not
your gut feeling is only good if you have reviewed the area concerned
always study the topic highlighted in the mcq
know why an option is correct and why incorrect
good resources for MCQ:
de Alwis Emergency medicine mcq
Dunn mcq's / Tintinalli mcq's
Today we reviewed the issue of tachypnoea in adults and looked at the USS protocol for lungs to help diagnose the cause of tachypnoea.
Key resources to review include Rosens chapter on Dyspnoea and an uss online atlas to help with lung USS such as radiopedia.
Key dichotomy in tachypnoea is respiratory vs non respiratory causes.
non lung causes include :
cns - ich
cvs - heart failure
toxicological -salicylates eg
metabolic - acidosis / DKA
LUNG USS key points
A profile - means lung is aerated - asthma and cold and pe still possible
A' profile - A lines but no lung sliding - pneumothorax, pleurodesis or fibrosis with loss of volume are main dd.
B profile - fluid in interstitial space - usually pulmonary oedema
A/B profile - focal areas with fluid accumulated suggests pneumonia
C profile - fluid in alveolus - consolidated lung - usually pneumonia
Check out the webinar online / to stream to review in detail
We completed a thorough review of the CXR interpretation in pneumonia and highlighted the following key points for ED practice:
ED Physicians will usually not know the cause of the pneumonia during acute assessment and subsequent admission.
Epidemiological risk stratification is therefore vital to guide empiric antibiotic choice.
Imaging, CT, lab tests usually will not identify the type of organism causing the illness.
Severity assessment is important to predict need for ICU care and guide initial abs choice.
CAP in immunocompetent patients with no other significant comorbidities is likely to be caused by viruses including rev and influenza. The key bacterial causes include
strep / haemophilus / moraxella / mycoplasma / chlamydia trachomatis
alcoholic / diabetic patients - add klebsiella
immunodeficient / hiv patients - staph / p jerovecii / tb
cohorts near water sources - legionella
AIDS or cell mediated immunity deficient - viral pneumonia herpes and cmv
PSI / smart cop / curb 65 - know the components of scoring and what the scores identify
A good review of subject in Rosens and also UpToDate.
PE-classification massive, submassive, non massive
This was a tough session today with some difficult cases and questions. PE classification based on clinical shock, uss evidence rv dysfunction or tn leak indicating damage or dysfunction. Check out Dunn or UTD on this topic
HIV and fistula
Very low CD counts = Cell mediated immunity severely affected = viral infection, fungal infection, then TB and microbes. See the document on UTD regarding immune deficient patients such as HIV or chemotherapy patients. Also review Harrisons for a good review of the subject. Pertinent as a disease modifier on the floor and in exams.
Risk factors - esp alcoholic patients / boerhaves
present with chest pain and sepsis
cxr findings can be subtle - cardiac borders outlined sharply, continuous diaphragm sign etc - check radiopedia or Rabi et al.
polymicrobial - needs broad spectrum management of sepsis - NGT / enteric tubes for feeding
This is not an easy thing to do. The source of the wct is from outside the normal Sa- avn - his purkinje system. In both VT and wpw avrt anti d, the source is from a nidus outside this system and in the ventricle.
The following rules were developed knowing that it is an imperfect science. Wpw avrt ant d occurs in 6% of wct. It should be considered in patients without structural
Heart disease or the common risk factors for VT ie ischemia and cmo.
Look at V4-V6
If all qrs complexes r negative = VT likely
If positive , look for qR in V2-6 , if present = likely VT
If not - look for av dissociation - If present = likely VT
If none of above is present, consider wpw avrt antidromic circuitry
Do not give adenosine or any drug that could block the av node.
DC cardio version synchronized in a well patient 100J or unsychronised in a ALOC patient is the treatment option if wpw antidromic avrt is considered.
Many em doctors have asked what is the best way to prepare or practice MCQ’s.
I suggest the following :
Join ACE the ACEM ! We will cover about 100 MCQ’s in detail over 6 months during the course !
Have a look at
MCQ’s will be released on that sister site focusing on PEM topics with discussion of answers during the course.
An excellent text to review is
Emergency Medicine MCQ’s
by Waruna de Alwis and Yolande Weiner
It has a range of contributors ( including me 😁 - no financial interest though) and really covers the breadth of EM well.
It has a large bank of mcq’s Written by facems who are involved in acem exam teaching. The commentary and references are pretty good.
A review of the MCQ packages attached with one of the main texts :
Is a good way of covering all the syllabus. Because time is short - I suggest just going thru 1 of these packages combined with the above resources first.
We completed a very important session today - Resuscitation and shock.
Review the documents published by Ilcor - these are vital to review.
Download the resus booklet published by Ilcor.
Review the documents published by Australian Resuscitation Council.
Areas for specific review include neonatal and paediatric resuscitation.
Post cardiac arrest hypothermia also important.
Inotropes, aortic balloon pumps, LV assist devices and ECMO are receiving increasing attention from acem.
Classification of shock and the surviving sepsis campaign 3 for Australia are further areas we reviewed.
The first session of cardiology 2 has just wrapped up. It was a tough session with some tricky subjects covered. The team doing the session actually did very well considering the difficulty of the questions.
Takotsubo syndrome - review uptodate
- mimics acs, no CAD on angio, modest rise of trop too small for the level of distress and pain and cardiomyopathy present, apical hyokinesis on bedside echo,
mayo clinic criteria
bnp pro / tn I ratio most sensitive marker
physical stressors more prevalent then emotional stressors
VT - review uptodate
VT vs SVT vs WpW AVRT
VT - concordance, av dissociation, NW axis, fusion or capture beats
VT vs wpw avrt - v4-v6 - ? negative ? qR - if not - consider wpw
Aortic Dissection - review uptodate or emedicine
clinical features - risk stratification - complications - ecg findings - classifications - compare the tests - management
- aortic vlave leaf malcoaptation
- ant impulse therapy in ed
- learn infusion doses for esmolol / labetolol / metoprolol / SNIP
- know to read a cross section CTA
Key concepts covered in the cardiology webinar today:
Chest pain stratification scores :
ED ACS ( accelerated chest pain pathways)
Aus cardiology society cp guide - high intermediate and low risk
Approach to an ECG:
PR / elevation - depression / P Ta elevation
QRS - rule out BBB / LVH / hocm / ER / brugada first
Then consider ST segment for stemi or nonstemi
Drugs / dig / electrolytes / toxin
STEMI patterns on the ECG, localization of the lesion eg anterolateral stemi, correlation with specific coronary vessels involved
STEMI differential - note not all stemi has reciprocal change
Early depolarization ( low medium high risk)
Ventricular hypertrophy / hocm
Arrhythmia eg brugada
Takotsubo - 💔 broken heart syndrome
Inflammation - pericarditis / myocarditis
Osbourne waves / hypothermia
Vasospasm - prinzmetal angina
AVR - ‘the death lead’ - elevation > 1mm and more than V1 with widespread Sr depression = Left main stem equivalent lesion.
Posterior STEMI diagnosis - look for V1-2 st depression r/s ratio > 1 and upright T waves
Right ventricular STEMI diagnosis
Atrial infarction with PTa elevation - increased mortality
RBBB - acs and STEMI diagnosis is complicated.
AF and flutter guidelines - rate vs rhythm control, drugs to use, chadsvasc2, hasbled score
MJA AF guideline.
Still another 150 ecg’s to go !
Happy studying ! 💔 🖤😎
It’s really important to structure your thought processes when studying for the exam or working on the floor in ED. The process of thinking about how you think is called metacognotion. Understanding metacognition is essentially what the acem Exam, and patients on the ed floor, tests in a rigorous and sometimes unforgiving way - how does a good ED Physician think ...
This blog will be updated regularly with good strategies for thinking under pressure.
Administration or troubleshooting scenarios
Personnel ( doctor, nurse etc)
Patient ( characteristics, medical history etc)
Disease Process ( is it getting worse, complications etc)
Equipment ( ventilator failure, lead misplaced etc)
Environment ( how busy is the ed / regional vs tertiary)
Generating valid Differential Diagnoses
There are multiple strategies for this key skill in medicine, but here is my take on things:
Diagnostic reasoning is a process difficult to study - it’s a fluid organic process that gets better with age, experience and exposure to more complex and difficult scenarios.
A Process Sieve/ sorter could include :
C - congenital
H - hormonal / endocrine / metabolic
I - infective / inflammatory
N - neurological
N - neoplastic
P - psychogenic
A - autoimmune
R - respiratory / renal
V. - vascular
O - ortho
S- social / sexual
T - trauma / toxin
D - drugs
CHINNPARVO STD - was a mnemonic I created at Med school when I knew very little and it’s stuck with me for 20 years !
SYNDICATE is one I have seen used in Oz.
Create your own pathophysiological sieve.
A second option to use or combine is an anatomical approach:
Head / cns
Git - oesophagus stomach duodenum
Liver pancreas gallbladder
Sexual organs / reproductive
Muscles / bones and nerves.
The neuro system is particularly difficult and a good approach includes the following :
Upper motor neurone
Lower motor neurone
Motor cortex - homonculus
Wernickes and Brocas speech areas
Pond and midbrain lesions
Basal ganglia systems ( Parkinson’s etc)
Medulla and resp Centre
Spinal cord and it’s architecture
Spinothalamic tracts (sensory from cord to brain)
Corticospinal tracts ( motor from homonculus to spinal to muscle)
Posterior columns ( proprioception)
Motor end plate